Burnout and resilience in intensive care Nursing professionals in the face of COVID-19: A multicenter study

Abstract Objective: to analyze the relationship between the Burnout dimensions and the work resilience of intensive care Nursing professionals in the COVID-19 pandemic in four hospitals from southern Brazil. Method: this is a multicenter and cross-sectional study, composed of 153 nurses and nursing technicians of the Intensive Care Units. Sociodemographic, health and work-related questions were collected, and the Maslach Burnout Inventory and Resilience at Work Scale 20 instruments were applied. The data were submitted to descriptive analysis and to bivariate and partial correlations (network analysis). Results: work resilience presented an inverse correlation to emotional exhaustion (r=-0.545; p=0.01) and depersonalization (r=-0.419; p=0.01) and a direct one to professional achievement (r=0.680; p=0.01). The variable with the greatest influence on the correlation network was the perception of the impact of the pandemic on mental health. Conclusion: resilience interferes in the emotional exhaustion and low professional achievement domains of Burnout. Emotional exhaustion is conducted through minor psychological disorders, with an impact on the workers’ physical and mental health variables. The development of institutional resilience should be encouraged in order to moderate the illness.


Study variables
The questionnaire contained sociodemographic

Instruments used to collect the information
To evaluate the Burnout syndrome, the Maslach Burnout Inventory (MBI), validated in Brazil, was used (7) .

The instrument has a five-point Likert scale and 22
questions. Nine questions assess emotional exhaustion Rev. Latino-Am. Enfermagem 2022;30:e3537.
As a strategy during data collection, visits were made to the units to invite the professionals who had not been granted access to the research instrument and also to remind them about the study.
In view of the limitations related to the critical pandemic period, it was not possible to carry out supervision tasks during completion of the forms.
However, all professionals were instructed to answer them.

Data treatment and analysis
The data were stored in Excel ® spreadsheets and later transferred to the SPSS ® Statistical Package for the Social Sciences, SPSS Inc, Chicago), version 18.0 for Windows, and to the JASP platform -Jeffreys's Amazing Statistics Program (version 0.14.1) (17) . A descriptive and inferential statistical analysis was performed.
Distribution of the variables was verified using the Shapiro-Wilk test, considering p≤0.05 to indicate nonadherence to normal distribution. The parametric variables (age and time working in the profession) were described as mean and standard deviation. The other continuous, non-parametric variables were described in medians and interquartile intervals. The data obtained by means of the Likert scale were described in medians and interquartile ranges. The categorical variables were presented through of absolute and relative frequencies.
To verify the correlation between the variables, bivariate Spearman correlations were performed, suitable for analyses that include ordinal and continuous variables. To evaluate the difference between two groups and the Burnout syndrome domains (Emotional Strain, Depersonalization and Professional Achievement), the Mann-Whitney test was used and, for more than two groups, Kruskal-Wallis and Dunn. Therefore, it was verified which independent variables (sociodemographic, health and work-related variables) presented a significant relationship (p<0.05) with at least one of the dependent variables.
To investigate the relationship between Burnout and resilience at work, a network analysis was carried out, which comprises two stages: the first consists in estimating the matrix of regularized partial correlations The resulting non-directional network is formed by vertices, representing the variables investigated, and by edges, representing the partial correlations among them.
The partial correlations can vary in magnitude (more or less thick lines) and in positive (blue) or negative (red) direction (21) . This analysis identifies the associations between two variables after controlling the effect that all others have on them; thus increasing the certainty of the inferences presented in the previous analyses.

Ethical aspects
The study was approved by the Research Ethics

Results
The highest percentage of the participants corresponded to the female gender (78.4%; n=120).
Regarding life habits, 30.1% (n=46) reported an increase in alcohol consumption during the pandemic and 92.2% (n=141) were non-smokers. Physical activity was reported by 26.8% (n=41) of the workers. In addition to that, the perception of sleep quality had a median of 3 (2-4).
The work-related characteristics of intensive care Nursing professionals are presented in Table 1.

Discussion
The findings of this study evidenced resilience at work as a protective factor in the presence of high levels of emotional exhaustion and depersonalization, domains with the highest scores in the Burnout syndrome.
A number of studies (23)(24)  Council (34) , 44,441 nurses, technicians and assistants were distanced from work in 2020, after infection with the new coronavirus. In addition to the factors that involve workers' exposure, exhaustion also became a concern due to the increased risk of errors with personal and assistance care measures, considering the extreme fatigue of the teams due to the long period of work and stress (34) .

Sleep quality and performance of physical activities
showed a positive impact on physical health and a protective factor for minor psychological disorders. It is known that sleep has a function of physical restoration, conservation, energy and protection (35) and that the practice of physical exercise is fundamental for maintaining health. Due to the pandemic and the high number of leaves, many professionals faced double working hours, as well as high workload and stress, factors that can affect sleep quality. In addition to that, the need for a lockdown and social isolation restricted leisure activities and sports, harming health and quality of life (36) .
A study carried out in China indicated that working on the front lines in the fight against the pandemic was, Vieira LS, Machado WL, Dal Pai D, Magnago TSBS, Azzolin KO, Tavares JP.
significantly, associated with increased anxiety and stress levels, with a negative influence on the professionals' sleep quality (37) . Greater susceptibility to depressive symptoms, anxiety, stress and sleep-related problems in women and nurses has also been reported, considering the places with the greatest focus of the pandemic as a heightened risk for these symptoms (38) . The authors reinforce the link between sleep and mental health, in which insomnia can be related to psychopathologies such as depression or post-traumatic stress disorder, after a stressful event.
In addition to that, people who suffer from insomnia have greater difficulties dealing with daily stressors (39) .
Regarding the practice of physical activities, a study showed a lower risk of illness for the group that exercised regularly (40) . Performance of physical exercises is capable of producing beneficial effects for physical and mental health, being considered effective in the prevention of mood disorders and neurodegenerative diseases through mechanisms involved in the organs-brain signaling axis (41) .
Resilience at work proved to be a protective factor were mediators in the Burnout domains, whose study proposes to establish resilience strategies for front-line health professionals to reduce burnout (42) .

A study conducted with front-line female nurses from
Philippines also evidenced that increased levels of personal resilience, organizational support and social support in nurses were associated with reduced anxiety levels related to COVID-19 (43) .
Our findings evidenced a direct relationship between emotional exhaustion and longer time in the profession.
In the literature, professional experience tends to improve sound awareness in problem solving, which can increase confidence in the professional actions, inducing less stress and anxiety (33) . However, a number of Italian authors, who reported their perspectives within an Intensive Care Unit during the pandemic, highlight that older and more experienced nurses needed to train new Nursing professionals, due to care complexity. Therefore, the responsibility was assigned to guarantee a high level of care and, at the same time, support less experienced Nursing colleagues, making their work routines more intense and stressful (44) .
As for work shift, the morning professionals presented an inverse relationship to resilience at work. As limitations, the cross-sectional design does not allow monitoring the individuals to verify the impacts of the pandemic on mental health, requiring a cohort study.
There are also few investigations that assess resilience at work with the instrument used, creating difficulties in corroborating some results. In our study, only healthy workers were included, as well as an important percentage of new workers in the profession and in the institution, with attenuated risk factors for developing Burnout syndrome in the first moment of the pandemic, when data collection took place.